Nutritional Therapy

The role of nutritional therapy as a primary therapy for CD is controversial. There is no convincing control-trial evidence that enteral nutrition (EN) alone is effective for the treatment of active CD, and there appears to be no difference between elemental and nonelemental diets. Furthermore, both elemental and semi-elemental diets are nonpalatable and patients are unlikely to be compliant with this therapy. They may be considered in patients where other therapies, either medical or surgical, are not effective or not desired. See section below and separate chapter on enteral or parenteral therapy as an adjuvant (see Chapter 54, "Enteral and Parenteral Nutrition").

The use of growth hormone (somatotropin) in combination with nutritional therpay may be beneficial in patients with active CD, particularly in children with steroid-dependent disease. In a preliminary randomized, double blind, placebo controlled study, growth hormone was administered subcutaneously at 5 mg/d for 1 week followed by a maintenance dose of 1.5 mg/d for 4 months, while the patients increased their protein intake to > 2 g per kg of body weight per day (Slonim et al, 2000). Whether this benefit will hold up in large, randomized controlled study and the long term effect of growth hormone therapy still need to be examined.

EN, however, is an adjunct in the management of CD. This is particularly important in children or adolescents, and in patients with SB CD and compromised nutritional status. Avoidance of lactose-containing foods may be beneficial in some but not all patients. Patients with symptomatic fibrostenotic disease should be instructed to avoid high residue diets. Patients who are placed on bowel rest because of penetrating or obstructive disease should receive parenteral nutrition (PN). Routine PN supplement has no role in SB CD if patients are able to tolerate EN and maintain adequate nutrition (Ostro et al, 1985). Prolonged bowel rest and PN may be required in a small group of patients with multiple SB strictures, fistulas, and/or complications of medical therapy who are not surgical candidates. In these patients with essentially gut failure, home total parenteral nutrition (TPN) is necessary not as a primary therapy but to provide nutritional support. Whether SB transplantation may be beneficial in these patients still needs to be seen.

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